The competency based medical education model is part of an important philosophical shift in thinking about assessment and its purpose. In shifting emphasis from Assessment OF Learning (summative assessment) to Assessment FOR Learning (formative assessment), the coaching model uses assessment as a learning tool, not just an evaluation method.
In addition to the oversight of patient care, expectations of a clinical teacher now include more observation and coaching of residents.
The Royal College of Physicians and Surgeons of Canada (RCPSC) have developed a coaching model (see graphic below) to support resident learning. The Competence by Design (CBD) coaching model includes 2 coaching components – Coaching in the moment and Coaching over time – both of which are integral to the growth and improvement goals of Competence by Design. While the model has been developed by the RCPSC, these concepts have been adopted by the College of Family Physicians of Canada.
Resident learning is the focal point at the top of the graphic and reflects the importance of a learner-centered, developmental approach to competency acquisition.
Coaching feedback is the prominent method to facilitate the learning and development.
There is also a deliberate direct connection between the resident and the coach illustrating the importance of the collaboration that must occur between those involved in these roles for the benefit of resident learning and progression.
The foundational layer, the Health Care System, is a recognition that resident learning and coaching is occurring within the workplace of the complex health care system and that real patient care is part of the learning context.
The following chart explains the difference between traditional teaching, mentoring, and coaching.
|To transmit a specified body of knowledge and skills to Learners
|To guide mentees in achieving performance and career growth
|To facilitate skills needed to achieve performance enhancement and growth
|Qualities of Faculty
|Understand what is required for expertise
Achievement of required curricular objectives (tests)
Uses expertise and experience to guide,advise and endorse mentee
Engages Learners in self regulated learning through observation, feedback and goal setting
|Relationship to Learner
All Learners treated the same
Their judgement and expertise primary in guiding mentee
Reciprocal, collaborative trust relationship
Individualized to coachee abilities and goals
|Specific to the program/course
|Short or long term
Coaching feedback is a key component in both Coaching in the Moment and Coaching over Time. Coaching feedback is for learning, and not for assessment.
Coaching feedback is:
- a conversation between learner and clinical teacher to enable learners to enhance their performance.
- identifies what was observed.
- encourages learner self-reflection and goal-setting.
- focuses on specific actions for improvement.
Coaching in the moment is part of the role of the clinical supervisor or the individual who is observing the learner. In broad terms, a coach is a person who can help learners reflect on where their performance stands and how to improve (Deiorio 2016). Coaching is beneficial for anyone who is pursuing optimal performance.
- Coaches can help an individual to do a task better, develop a skill they don’t yet possess or achieve a specific goal.
- Coaching helps a learner understand what adjustments and modifications will allow them to progress to the next level of capability/proficiency.
- Coaching is giving actionable concrete suggestions for improvement.
These same principles apply in the clinical setting.
Academic coaching is a “one-to-one conversation on the enhancement of learning and development through increasing self-awareness and a sense of personal responsibility, where the coach facilitates the self-directed learning of the learner through questioning, active listening, and appropriate challenge in a supportive and encouraging climate” (Van Niewerburgh C, 2012).
Judgment is NOT the purpose of the observation (assessment). Of course, a coach will make decisions about the quality of the task performed, but a coach’s priority is to promote improvement.
Coaching in the moment is:
- workplace-based, occurs in a clinical environment.
- a key component of workplace-based learning.
- part of normal learning activities.
- low stakes and frequent.
- timely and efficient.
- guidance for improvement.
Coaching in the moment is foundational to competency focused instruction and workplace-based learning. It is a process that is to occur in-the-moment, close to the time the observation occurred, and in a clinical environment.
Clinicians observe learners doing their daily work. The observations are shared with learners in a way that guides learning and improvement and then the observations and feedback is documented for the learning portfolio.
The RCPSC has developed a process to support coaching in the moment called RX-OCR.
- Establish educational Rapport between the resident and the clinician (an educational alliance or partnership).
- Set eXpectations for an encounter (discuss learning goals).
- Observe the resident (directly or indirectly).
- Coach the resident for the purpose of improvement of that work (“coaching feedback”).
- Record a summary of the encounter.
Coaching Over Time calls for a longitudinal educational partnership between a clinician and a learner for the purpose of progression of competence and development of lifelong learning skills (for eventual self-regulated learning). This clinician-learner relationship lasts longer than any one clinical experience, and this extended period of time allows for the relationship to be deeper than that formed during Coaching in the Moment.
With competency based medical education and work-based assessments, learners will receive many types and a far greater volume of assessment data, the most frequent of which should be recorded observations that happen in the course of day-to-day clinical work (coaching in the moment). These data windows (snapshots of work over time) will illuminate the bigger picture of how the learner is progressing toward competence.
Coaching Over Time involves deep, authentic and reflective discussions, sees and addresses patterns, and plans how to address gaps and issues. Given the potential content of such discussions, assuring a safe learning environment is essential. This role could be filled by a program director, faculty advisor (optional), etc.
Coaching Over Time involves:
- a longitudinal educational relationship between faculty and resident over time beyond a single clinical encounter.
- regular reviewing, synthesizing multiple sources of data in order to provide feedback on learner’s progress.
- helping learners reflect on progress based on feedback and set specific learning goals and plans.
- following up on action plans and progress.
- facilitating learner’s understanding of ways of improving performance through development of guided self-regulated learning skills.
Having established clinical credibility, residents then consider:
- Resident perception of teacher’s interest, commitment to their learning and development.
- Mutual understanding of learner’s goals and how to achieve them.
- Resident perception of being liked.
Telio et al 2015, 2016
How coaches build this alliance:
- Invest time in knowing the resident’s story – past experiences, life situation, interests, goals.
- Provide clarify about your role, expectations (yours and the program’s), and your hopes for the relationship.
- Be available, accessible, affable (the Triple A).
This diagram reflects the self regulated learning cycle (the coloured boxes). Effective learning involves moving through each of these steps. However, it is not easy to do this on our own and the grey boxes reflect actions that the academic coach can do to facilitate each step. Relationship building underlies the entire process.